Basic Information
| Provider Information | |||||||||
| NPI: | 1467685073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHARATH | ||||||||
| FirstName: | KOMAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VENKATAKRISHNAN | ||||||||
| OtherFirstName: | KOMALAVALLI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 CHESTNUT ST | ||||||||
| Address2: | 2 LIBERTY PLACE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191920001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2678382061 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 333 COTTMAN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157282844 | ||||||||
| FaxNumber: | 2152141425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2009 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD443523 | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | MD443523 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 037276 | 01 | PA | MLHC MEDICARE AA # | OTHER | 100727800 | 01 | PA | TPI MEDICAID GROUP | OTHER | CD4829 | 01 | PA | TPI RAILROAD MEDICARE GROUP | OTHER | 597586 | 01 | PA | TPI MEDICARE GROUP PIN | OTHER | 824305 | 01 | PA | MLHC B/S AA #: | OTHER |